NURSING CARE PLAN 1

NURSING
CUES GOAL NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE FLUID VOLUME DEFICIT Within 8 hours of INDEPENDENT Within 8 hours of
related to osmotic rendering holistic nursing rendering holistic nursing
>” Sige man ko ug diuresis secondary to care, the patient will : 1. Obtain history of illness 1. Assist estimation of total volume care, the patient achieved
uhawon. Ganahan ko increased blood glucose depletion. Symptoms may have and demonstrated
mo inom ug tubig kay levels >Achieve/Demonstrate been present for varying amounts evidences of adequate
dali ra magmala akong adequate hydration as of time. hydration and stable vital
baba” as verbalized evidenced by stable V/S signs:( with moist lips and
and increased intake of 2. Monitor BP changes 2. Hypovolemia is manifested by minimal moisture on skin;
OBJECTIVE Inference: fluid. hypotension along with tachycardia vital signs as follows:
 Increased serum and tachypnea; estimates of the T – 37.4 °C
> Received on bed in glucose levels severity the hypovolemia may be P – 85 bpm
supine position, with an made when BP drops more than R – 21 cpm
ongoing IVF of PLR 1L @  F & E from cells are 10mmHg BP – 110/70 mmHg
900 cc level, regulated pulled by greater
at 40 gtts/min, hooked osmotic power of 3. Assess peripheral pulses, capillary refill, 3. Indicators of level of DHN, and
at right cephalic vein, glucose skin turgor and mucous membranes. circulating volume adequacy
with Foley bag catheter
attachment  Cellular dehydration 4. Monitor I & O, calculate 24-hour fluid 4. Provides ongoing estimate of
balance, weight daily and monitor urine volume replacement needs, kidney.
Urinary output of 400-  Kidneys excrete specific gravity.
600 cc per shift excess glucose
5. Provide frequent TSB. 5. TSB promotes skin moisture and
>Diluted urine, color is  Water is pulled prevents dryness. Also promotes
yellow because of high comfort of patient.
osmotic power of
>Thirsty most of the glucose(osmotic 6. Discourage intake of alcoholic and 6. Alcohol and caffeine exert a diuretic
time, takes frequent sips diuresis) caffeinated beverages. effect increasing fluid loss.
of water
 Increased 7. Provide frequent oral care and eye 7. Fluid losses from body, decreases
>Dry lips with cracks urination(polyuria) care. the skin and mucosal moisture
noted thereby rendering the area
susceptible to injury.
>Dry skin with little to
no moisture noted
Poor skin turgor noted
8. Promote patient safety. 8. Patients manifest symptoms of
>Vital Signs as follows: decreasing LOC with fluid loss
T - 38°C making patient susceptible to
P – 110 bpm accidents.
R – 36 cpm
BP – 100/60 mmHg

9. Keep fluids within clients reach and 9. Encouraging patient to rehydrate

encourage frequent intake not less maintains fluid balance and
than 1500 ml/day. replaces fluid loss from present
condition.

COLLABORATIVE COLLABORATIVE

1. Do IV follow-ups, as ordered. 1. IV therapy promotes rehydration

and restores fluid balance.

2. Monitor indwelling urinary catheter and 2. Monitoring the placement of the

urinary output. catheter and bag ensures
prevention of infection; the urine
output must be monitored for
color, consistency, specific gravity
and composition to determine
degree of renal function.

3. Administer medications as indicated. 3. Insulin injection promotes

utilization of glucose to cells.

4. Monitor and regulate IVF as ordered. 4. This is to prevent over infusion and
under infusion of patient; IVF
therapy replaces fluids and
electrolyte losses.

5. Monitor lab studies, e.g.

Hct; Assesses level of hydration and is often

elevated because of hemoconcentration
that occurs after osmotic diuresis.
BUN/Cr; Elevated values may reflect cellular
breakdown from dehydration or signal the
onset of renal failure.

Serum osmolality; Elevated due to hyperglycemia and

dehydration.

Sodium; May be decreased reflecting shift of fluids

from the intracellular compartment
(osmotic diuresis).

Potassium; Initially, hyperkalemia occurs in response to

acidosis, but as this potassium is lost in the
urine, the absolute potassium level in the
body is depleted. As insulin is replaced and
acidosis is corrected, serum potassium
deficit becomes apparent.
 NURSING CARE PLAN
2
CUES NURSING DIAGNOSIS GOAL NURSING INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE ALTERED NUTRITION less Within 8 hours of INDEPENDENT Within 8 hours of
than body requirements rendering holistic nursing rendering holistic nursing
>”Di man ko ganahan related to decreased care, the patient will: 1. Determine pt ability to chew, swallow 1. Patients with upper GI problems care, the patient
mukaon, sahay di sad appetite, painful a. Take in and taste food. may manifest difficulty in chewing manifested increased in
ko pakan-on, ga sigi ra chewing and swallowing, appropriate and swallowing. food intake; able to finish
ug lugaw,” as verbalized insulin deficiency and amounts of ¾ of her meals.
presence of infection. calories and 2. Ascertain client’s dietary program and 2. Identifies deficits and deviations
OBJECTIVE nutrients as usual pattern; compare with recent from the therapeutic needs.
evidenced by intake.
> Received on bed in Inference: increased in food
supine position, with an intake. 3. Provide liquids containing nutrients and 3. Oral route is preferred when client is
ongoing IVF of PLR 1L @ Presence of oral thrush + electrolytes. alert
900 cc level, regulated disease state
at 40 gtts/min, hooked 4. Discuss eating habits, including food 4. To determine appeal to clients likes
at right cephalic vein, Results to lesions which preference and intolerance. and dislikes.
with Foley Bag Catheter can cause local pain on .
attachment oral cavity
5. Observe for presence of hypoglycemia, 5. Once carbohydrate metabolism
 Lack of interest Chewing and swallowing e.g., changes in LOC, cool/clammy skin, begins (blood glucose level reduced),
in food noted is affected rapid pulse, hunger, irritability, anxiety, and as insulin is being given,
headache, lightheadedness, shakiness hypoglycemia can occur.
 Complains of Changes in
difficulty and appetite(decreased) 6. Observe presence of subcutaneous 6. This may indicate protein-energy
pain when fat/muscle wasting, loss of hair, malnutrition.
chewing and Decreased food intake fissuring of nails, delayed healing, gum
swallowing bleeding, swollen abdomen.
Nutrition is altered
 Facial grimacing 7. Auscultate bowel sounds, note 7. This is needed to evaluate the
when characteristics of stool. degree of deficit.
swallowing
noted 8. Encourage adequate rest and sleep 8. Adequate rest and sleep periods
periods. decreases caloric demand and
 Weakness noted prevents fatigue.
 9. Include SO in meal planning, as 9. Promotes sense of involvement,
indicated. provides information for SO to
 Decreased understand nutritional needs of the
movements patient.
noted
10. Provide simple health teachings to 10. Simple health teachings promote
patient and SO regarding management client and SO education and So
of DM type 2. involvement. Promotes
independence of client as well.

>Vital Signs as follows:

T - 38°C COLLABORATIVE COLLABORATIVE
P – 110 bpm
R – 36 cpm
BP – 100/60 mmHg 1. Monitor and regulate IVF and do 1. Monitoring IVF regularly prevents
follow-ups as ordered. overinfusion and underinfusion of
client. IV follow-ups are for fluid
replacement.
 NURSING CARE PLAN 3
CUES NURSING DIAGNOSIS GOAL NURSING INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE Fatigue related to Within 8 hours of INDEPENDENT Within 8 hours of
decreased metabolic rendering holistic nursing rendering holistic nursing
>” Kapoi man ug lihok- energy production from care, the patient will: 1. Discuss with patient the need for 1. Education may provide motivation care, the patient displayed
lihok, unya naa pa jud decreased appetite, activity. Plan schedule with patient and to increase activity level even improvements in ability to
ning catheter,”as altered body chemistry: A. Display improved identify activities that lead to fatigue. though patient may feel too weak participate in desired
verbalized insufficient insulin, and ability to initially. activities.
increased energy participate in Evidence: The patient
OBJECTIVE demands: presence of desired activities. 2. Alternate activity with periods of 2. Prevents excess fatigue. showed appetite during
infection. rest/uninterrupted sleep. mealtimes and was able to
> Received on bed in reposition herself with
supine position, with an Inference: minimal assistance.
ongoing IVF of PLR 1L @ 3. Monitor pulse, respiratory rate, and 3. This indicates physiologic levels of
900 cc level, regulated Decreased appetite blood pressure before/after activity. tolerance.
at 40 gtts/min, hooked results from presence of
at right cephalic vein oral thrush; mastication 4. Discuss ways of conserving energy and 4. Patient will be able to accomplish
with Foley bag catheter and swallowing are encourage adequate rest and sleep more with a decreased expenditure
attachment altered. periods. of energy.

>Weakness noted
Insufficient insulin leads
>Limited movements to decreased uptake of 5. Increase patient participation in 5. Increases confidence level, self-
noted glucose to cells thereby activities of daily living as tolerated. esteem as well as tolerance level.
causing weakness.
>Lack of interest in 6. Encourage patient to take in adequate 6. Appetite to eat is necessary in
activities noted food and promote appetite. order to provide extra energy and
Presence of infection prevent further fatigue.
triggers the inflammatory
process and the immune 7. Encourage fluid intake of not less than 7. Adequate fluid intake replenishes
>Vital Signs as follows: system to react against 1,500 ml/ day. fluid loss.
T - 38°C the causative agents.
P – 110 bpm Therefore, there is an
R – 36 cpm increase in the metabolic
BP – 100/60 mmHg demands of the body. 8. Promote safety of patient. 8. By assisting patient with
ambulation, the patient’s safety is
promoted preventing any
accidents.
9. Provide health teaching with patient
regarding condition and how to
prevent fatigue.
10. Involve SO with patient care and
health teachings.
9. Health teachings increases
patient’s awareness and promotes
independence.
10. The SO should be involved with
patient care and health teachings
to promote health education and
enabling SO to care for patient in
home-based care.